This summer three British transsexuals who want to be women won their appeal against the local health authority which had refused them a sex-change operation. In a case widely publicized in the UK, the Court of Appeal upheld an earlier High Court ruling that the authority had acted unlawfully, without consideration of what was “the proper treatment of a recognized illness.” The significance of this is that transsexuals in Britain, of whom around 1,000 are currently awaiting surgery, will now be able to demand to have their sex-change operations on the National Health. The solicitor representing the transsexuals commented at the end of this long-drawn-out case that the estimated å£200,000 spent on it could have funded twenty sex-change operations.

One of the transsexuals, known as “A,” was quoted as saying that the sex-change operation was essential to ending years of misery. “A” regards her male physique as a “deformity.” The agonizing sense of dislocation of a man who has been “born into the wrong body, and should really be a girl” emerged earlier in Jan Morris’s Conundrum (1974), a small classic of twentieth-century autobiography, the most convincing account of a sex change yet. Trapped in her male body, and known then as James, Morris endured military service (the 9th Lancers) and newspaper journalism (The Guardian and The Times), covering the war in Palestine and the ascent of Everest before taking the flight to Casablanca, where her penis and testicles were surgically removed and her vagina created in an expensive private clinic. No NHS option in the Britain of that time.

James/Jan Morris equated her conundrum with ideas of soul or self: “I think of it not just as a sexual enigma, but as a quest for unity.” Since then cultural historians have been productively exploring the connections between people’s perceptions of the body they see themselves as, ideally, inhabiting and their happiness of mind. In his earlier study of aesthetic surgery, Creating Beauty to Cure the Soul,1 Professor Sander L. Gilman gave a fascinating account of the origins of these ideas, tracing them back to Enlightenment philosophers’ understanding of a beautiful body as the visible expression of human virtue. Conversely, ugly bodies signified unhealthy spirits. Follow through this argument and the Jew’s nose comes to represent the Jew’s permanently sick soul.

In Creating Beauty to Cure the Soul Gilman concentrates on the complex relationship between aesthetic surgery and psychoanalysis in the late nineteenth and twentieth centuries, which offered parallel possibilities of transformation, one of the body, the other of the mind. While retracking over some of the same material, Making the Body Beautiful is a broader-based, less overtly academic work, written with some of the breeziness of Roy Porter’s energetic sociomedical overviews and containing an unforgettable collection of historical before-and-after photographs. Gilman’s book also differs in its focus from Elizabeth Haiken’s Venus Envy: A History of Cosmetic Surgery.2 Where Haiken drew the majority of her examples and conclusions from the US, Gilman ranges much more widely. His book shows a dazzling European erudition.

Central to Gilman’s thesis is the notion of “passing.” The reason for the popularity of plastic surgery (over 1.9 million operations in 1996 in the US alone) has been the way it helps people to “pass” into the social group with which they identify emotionally. The face was where it started. With their primitive grafts of flaps of skin, the earliest aesthetic surgeons were working to eliminate the facial evidence of unacceptable racial origins or undesirable disease. Gilman cites the sixteenth-century Italian surgeon Gaspare Ta-gliacozzi as the originator of flap graft techniques to replace a nose missing because of trauma or syphilis. These “virtual” noses had their inconveniences: they tended to get livid in cold weather; hard blowing could dislodge them. The techniques soon fell into disuse. More lasting was Tagliacozzi’s humane perception that a person without a nose was bound to be unhappy, and that this unhappiness could lead to illness.

The “cure” for the missing nose was rediscovered in 1794 in India, then under British colonial rule. News of the “very curious, and, in Europe, unknown chirurgical operation,” involving the use of a skin graft from the forehead, circulated in London in the Gentleman’s Magazine. By the early nineteenth century in Germany, Johann Friedrich Dieffenbach was pioneering more sophisticated methods, using a nasal bridge, to restructure the sunken syphilitic nose. In 1892, the American aesthetic surgeon Robert F. Weir butchered a live duck in the operating theater and used the duck’s breastbone to replace the nasal bridge of a syphilitic man of twenty-six.

Plastic surgery, a term in use from the early nineteenth century, was initially seen as nose surgery. Gilman gives detailed, often poignant case histories of Jews’ noses, Irish noses (often combined with notorious jug ears), Oriental noses, negroid noses, tumorous noses, such as appeared in cruel caricatures of J. Pierpont Morgan. He toys with the suggestion that President Clinton’s nose has dubious comic overtones reminiscent of W.C. Fields.


New surgery was developed to turn noses regarded as racially inferior into socially desirable features. In transforming the Irish immigrant “pug” nose into a real American nose, the late-nineteenth-century surgeon John Orlando Roe operated from within the nose so deftly that he left no scar. Roe also perfected a method of shaving the tumors off the face of a drunkard in a way that could transform his face into that of a good family man. “One could disguise the drunkard—but could one change his character?” Such questions are at the heart of Gilman’s book.

He tells a strange, macabre, and often richly comic story of shifting desires. The urgency of disguising racial origins diminished with the social acceptance of formerly marginalized races. The once-derided small, upward-tilted Irish noses, which signified the servile, suspicious immigrant classes, became the American and English fashionable ideal by the mid-twentieth century. Film starlets acquired retroussé noses set in gamine features, like the English actress Kay Kendall, whose nose had actually been formed that way in error by the famous New Zealand plastic surgeon Archibald McIndoe.

By the mid-1970s, a period of dawning ethnic pride, there were second thoughts on operations carried out to make blacks appear less negroid. It was now considered wrong to over-correct and create a nose that was racially incongruent. The much-maligned Jewish nose became an object of affection, even veneration, in the case of Barbra Streisand, seen as the acceptable face of Jewishness.

It was the development of anesthesia and antisepsis that allowed aesthetic surgery to flourish. By the end of the nineteenth century it had developed in its aims far beyond facial correction of racial difference. Gilman urges us to view the much-increased ambitiousness of both surgeons and patients in the context of the intellectual and cultural movements of the late nineteenth and early twentieth centuries. It was part of what Gilman calls “a sea change in imagining who we are and what our bodies are.”

The concept of aesthetic surgery as a Romantic calling arose among the European German-Jewish surgeons of this period. Jacques Joseph, the most influential of them all, saw himself as a sculptor of the human form, using techniques of rhinoplasty to bring his patients’ features close to an artistic classical ideal. His perfect female face had “a greco-roman profile with a 33 [degree] facial angle” and, interestingly, he used a portrait of his (non-Jewish) wife as an example, pointing out her similarity to a pencil portrait of a woman by Leonardo da Vinci.

Aesthetic surgeons overcame their relatively low status early in the twentieth century to attain respectability and even adulation. In both world wars they became the heroes of the hour. Jacques Joseph rose to fame when, in 1916, he took charge of the division for reconstructive surgery in the Charité hospital in Berlin, treating the terrible wounds endemic to trench warfare, caused as soldiers’ faces were exposed over the parapets. Gilman is at his best in a scintillating chapter on reconstructive surgery, commenting with his sometimes savage sense of irony that the sign of real success came when the patient was returned to his regiment to fight again.

The “erotic wounded warrior,” as Gilman calls him, has a haunting and ambivalent place in twentieth-century culture. Gilman might have referred here to the extraordinary series of seventy-two drawings, Studies for Facial Wounds, made in 1916 by the British artist Henry Tonks when he was attached to Harold Gillies’s facial reconstructive unit at Cambridge Hospital in Aldershot. These tragically accurate drawings are now at the Royal College of Surgeons in London. The sense of the soldier’s ruined splendor is poignant in Ernest Hemingway’s account, in A Moveable Feast, of facially wounded French World War I veterans, “les gueules cassées,” with their Croix de Guerre ribbons in their lapels. “There was always an almost iridescent shiny cast about the considerably reconstructed face, rather like that of a well-packed ski run.” Though eerie, these men remained objects of respect. Gilman points too to the physically destroyed but still vividly articulate Count Laszlo Almasy in Michael Ondaatje’s The English Patient. Ondaatje created “the horribly burned face and figure of the eponymous hero as the sign that defines all opposition to war.”

The fetid and duplicitous atmosphere of Nazi Germany encouraged the more dubious elements of reconstructive surgery. It had its role in manufacturing Hitler’s perfect military machine; in 1936 a new law authorized the state to reconstruct a soldier’s body “against his will if necessary, as to extract from it its maximum fitness.” In Fascist Italy, Mussolini’s army officers were ordered to have their eyelids examined and, if necessary, tightened up by surgery to improve their vision. Jews under the Third Reich took to aesthetic surgery to “disappear.” The circumcised penis became a thing of nightmare. Suspected male Jews interrogated on the streets of Berlin would, as a last resort, be told to drop their pants. The SS had been trained by Arab experts to distinguish between cuts made on the twenty-eighth day after birth, which identified a Muslim, and cuts made on the eighth day, which gave away a Jew.


Decircumcision has been possible for almost as long as circumcision has. Gilman finds Roman examples of surgical procedures for elongating or replicating the male foreskin. Hellenized Jews resorted to these in order to take part in the Greek athletic games, from which circumcised men were banned—rather as later Jews, excluded from dueling, went to cosmetic surgeons to fake their dueling scars. Gilman notes a greatly rising demand for decircumcision over the past decade in the United States. The rush for surgical restoration of the penis, amounting to “a small industry,” has taken place against a background of attacks on circumcision as a cruel, child-abusive, and medically unnecessary practice, and a decline in the practice of infant male circumcision itself. But, here again, human desires are variable: according to Gilman, while an “uncut” penis is currently de rigueur in gay circles in New York City, the circumcised version is more desirable in similar social settings in Germany.

Since both men and women have buttocks, why have buttock lifts come to be seen as an essentially female operation, like the reduction and lifting of breasts? Gilman shows how such early-twentieth-century works as Havelock Ellis’s Studies in the Psychology of Sex, following the reproductive theories of Charles Darwin, stressed the buttocks as a female secondary sexual characteristic highly fetishized in European culture. Ellis thought there was a connection between the British male obsessiveness with female buttocks and the national erotic sport of whipping, encouraged by the practice in British public schools. The well-formed young girl’s buttocks came to overtake the breasts in Ellis’s scale of bodily areas of sexual desire. When, in the 1970s, Brazilian aesthetic surgeon Ivo Pitanguy perfected his widely imitated buttock lift, this deemphasized the breasts and reemphasized the buttocks, arriving at an image of the female form resembling to an uncanny extent Ellis’s English “girl”—and indeed Sir John Betjeman’s erotic heroines of suburban tennis courts.

The large pendulous breast was seen for many centuries as a sign of the outré and primitive. Herman Heinrich Ploss’s ethnographic study of “woman,” first published in 1885, refers to the breasts of the “black” race as resembling a goat’s udder. The anthropologist Hans Friedenthal was even to claim, in his 1927 essay “Muttersprache and Mutterbrust,” that the structure of primitive languages was formed by the pressure of the savage mother’s breast, referring to nurture patterns among “Hottentots and Bushmen” and to the “strange sounds of their languages which is in harmony with the club-shaped breasts of the mothers which shaped the lips of the nursing child.”

Not surprisingly, the modern development of aesthetic breast surgery begins with demands for reduction. In the 1880s and 1890s surgeons expended much energy in evolving techniques to arrive at the perfect breast for the “New Woman,” with small, rounder breasts replacing large, cumbersome, old-fashioned ones, relieving stress on the back muscles and improving self-esteem. A hundred years later the shaping of the breast is still associated with race. In Brazil, breast reduction operations are commonplace in upper-middle-class families, and are often given as “sweet sixteen” birthday presents to their daughters to mark them out from female teenagers of the lower classes, whose heavy breasts stigmatize them as “black.” Conversely, in Argentina, young women are more likely to be asking for extensive breast enlargements, in line with the Spanish perception of the big-breasted woman as erotic. Here, according to Gilman, a million breast enlargements have been performed since 1970, one for every thirty Argentinians.

The medical response to the desire of so many aging people to “pass” for someone younger has a not altogether honorable history. Gilman identifies two “classic models.” First, total rejuvenation of the body by such means as the injection of canine semen (as performed by Brown-Séquard in Paris in 1889); the implantation of entire testicles donated by—apparently unwilling—monkeys (done by Serge Avramovitch Voronoff, again in Paris, about a decade later); and the “Steinach” system of unilateral vasectomy, which flooded the elderly male body with the accretions of the “puberty gland.” This was claimed to bring about a marked increase in the patient’s sense of happiness. But in 1926, when Sigmund Freud underwent a “Steinach” after he developed cancer of the jaw, hoping that rejuvenation would help him to recover, he was conscious of no benefits at all.

Gilman’s second category covers surgical procedures to return the face and body to the semblance of youthfulness. There has been an enormous, and still increasing, upsurge in demand for such treatments since the surgeon and cultural historian Eugen Holländer carried out the first face lift on a Polish female aristocrat in 1901. While reconstructive surgery has stayed at a fairly stable level over the past decade, latest figures from the American Society of Plastic and Reconstructive Surgeons show a 153 percent increase in “cosmetic enhancements” performed by plastic surgeons since 1992.

The rise can be attributed to advances in technique, less alarming procedures, and faster cycles of recovery in a world of “weekend face lifts” and “happy surgery.” Rejuvenation treatments are starting younger. Certain New York plastic surgeons are recommending annual “maintenance” procedures, such as the removal of fat from the neck and the elimination of worry lines, for women between the ages of thirty-five and forty-five.

There is now less furtiveness attached to aesthetic surgery. But the question remains—and Gilman asks it cleverly, humanely, and persistently—whether new appearances just gloss over old problems and often create new ones. In taking advantage of what surgery can offer, are we narrowing our expectations of human variation, of the dignity of aging? What are we making of ourselves?

In the late nineteenth century, most patients who had aesthetic surgery were men. Recent US figures show a rise in the number of male patients undergoing liposuction, eyelid surgery, and face lifts, among other “cosmetic” procedures:99,000 in 1998; 55,000 in 1992. But the figures for women are almost ten times higher. Aesthetic surgery has been a predominantly female issue in the twentieth century, and the feminist response to it in the 1990s has been deeply and often acrimoniously divided.

The conventionally paranoid feminist view of aesthetic surgery as male capitalist conspiracy was most powerfully expressed by Naomi Wolf in The Beauty Myth: How Images of Beauty Are Used Against Women.3 Here Wolf argued that the cosmetic surgeons’ direct financial interest in the number and extent of operations carried out created a cultural climate in which women were indoctrinated into feeling ugly and inadequate and therefore in need of treatment. As she put it succinctly: “The industry takes out ads and gets coverage; women get cut open.” This line of argument gets no support from Gilman, who points to the huge numbers of women seeking treatment and denies the likelihood that all are unintelligent.

The alternative feminist viewpoint proposes aesthetic surgery as female empowerment, by which a women takes full charge of her own body, amending it if she so chooses. This element of volition was the decisive factor in Kathy Davis’s sometimes anguished feminist commentary Reshaping the Female Body: The Dilemma of Cosmetic Surgery,4 leading her to the conclusion that tummy tucking can indeed be politically correct. Here, Gilman provides a useful historical perspective on the active role of patients in initiating treatment. Holländer’s Polish aristocrat, for example, arrived at her first consultation with a detailed drawing indicating how the effect of removing facial skin from the front of the ear would be to tighten up the corners of the mouth and the nasolabial fold. She had designed her new appearance. The first face lift was arguably more hers than his.

The most interesting recent intervention in this argument comes from Dr. Nancy Etcoff, a practicing psychologist, whose Survival of the Prettiest:The Science of Beauty offers a direct riposte to Naomi Wolf. Beauty is not a myth in the sense of a cultural construct or creation of manipulative advertisers. Wolf sees it as much more deeply rooted in our natures, claiming that our “passionate pursuit of beauty reflects the workings of a basic instinct.” She quotes Plato: “The three wishes of every man: to be healthy, to be rich by honest means, and to be beautiful.” She evokes George Santayana’s supposition that there must be “in our very nature a very radical and widespread tendency to observe beauty, and to value it.”

Her specific answer to Wolf is that Madison Avenue exploits but did not create our universal preferences. Etcoff’s references range intriguingly from academic anthropological, sociological, and psychological journals to more popular histories of fashion and beauty, Henry James’s Letters, Ovid’s Erotic Poems, and her own sharply contemporary professional and private observation of the way people behave. She claims that the sizing up of other people’s looks, and their rating for attractiveness, is a continuous and automatic process. Rapid too: “We can see a face for a fraction of a second (150 msec. in one psychology experiment) and rate its beauty, even give it the same rating we would give it on longer inspection.” Quite true.

Fifty years ago the ethologist Konrad Lorenz identified the onrush of human tenderness the small and defenseless baby’s features bring. Etcoff draws on new research to show that parents are more affectionate in their behavior to newborn babies who are physically attractive. “An ugly baby is a very nasty object,” as Queen Victoria apparently once said. The babies themselves discriminate in their responses: at three months old they can be seen to gaze for longer at attractive faces than at unattractive ones.

Etcoff describes the extent to which “lookism”dominates our transactions with each other, albeit often unconsciously. People viewed as beautiful, men as well as women, are treated preferentially. They find sexual partners more readily. Employment prospects are better. They tend to get more lenient sentences in court. They elicit help more easily. When seventy-five college men, in a psychologist’s test, were shown photographs of women of variable attractiveness and asked to say for which they would most eagerly move furniture, lend money, donate blood, donate a kidney, save from a burning building, and other knightly feats, beautiful women got more generous responses in all respects except that of lending money. It appears that men are less likely to ask good-looking women for their help. Such results from questionnaires, of course, raise questions of how closely they match actual behavior, and this is a question difficult to explore.

What does beauty consist in? Etcoff claims that what the human race finds beautiful are “those physical characteristics that suggest nubility, fecundity, health, and good design.” These are very general attributes, subject to different interpretations in every culture, and the reasons for particular differences remain obscure in Etcoff’s account. Anthropologists and psychologists have in the past suggested that a beautiful face is “average,” in the sense of displaying the features of the population mean—a reading that connects with Gilman’s theories of “passing.” But Etcoff brings in more research to suggest that, in our celebrity-minded culture, in the most beautiful people of all, a few (predictable) facial features differ from the norm. Naomi Campbell’s and Christy Turlington’s lips are different from those of most other people; Kate Moss’s “ledged cheekbones and delicate jaw line” would not qualify as average. In the realms of high glamour there is also an abnormal emphasis on youthfulness. When the facial proportions of cover girls from Vogue and Cosmopolitan are fed into a computer, it “guestimates” them as children between six and seven years of age.

The conviction of being attractive or unattractive can dominate one’s life. Etcoff cites Tolstoy, who could see no hope of happiness on earth for “a man with such a wide nose, such thick lips, and such tiny gray eyes as mine.” But one wonders whether Tolstoy or indeed George Eliot would have written so ambitiously or so profoundly had they been more conventionally beautiful. The consciousness of physical non-acceptability elicits an often dramatic response. In considering the numbers of Americans voluntarily undergoing aesthetic surgery involving tearing or burning their skin, sucking out their fat, or implanting foreign materials, Etcoff denies that this is symptomatic of a diseased culture within present-day America. “Throughout human history, people have scarred, painted, pierced, padded, stiffened, plucked, and buffed their bodies in the name of beauty.” The fact that four hundred women a day were receiving silicone gel breast implants before the FDAlimited their use in 1992 may indicate an increased degree of recklessness. But courting pain and danger is nothing new.

As with breasts, dissatisfaction with the penis can propel the owner into desperate remedies. The main motivation for the ten thousand Americans who have resorted to surgery to lengthen or widen their penises is not so often criticism from a sexual partner as what Etcoff describes as “locker room phobia”: the imagined derision of one’s peers. Maybe the panic has been accelerated by reports of a general reduction in size of the US male organ. Whereas archival data from the Kinsey Institute of Sex Research, based on a survey of some years ago, recorded the average length of the erect penis to be between 5 and 7 inches, more recent figures—based on a 1997 sample of over a thousand men—show a greater proportion of shorter erections, measuring from 4.5 to 5.75 inches and accounting for 40 percent of the total. (Even more different in relation to the twelve-inch erection in the beautifully delineated “Studies of Parts”—kept in a locked safe in the British Museum—by the English artist Eric Gill.) Penis lengthening, a matter of cutting two ligaments attaching the penis to the pubic bone, so that it descends further down the body, has been carried out with relatively few problems. Similar procedures have been carried out on men in Britain, Japan, Australia, and other countries. Penis widening, by means of injection of fat, is more of a gamble, since the head, or glans, cannot be enlarged proportionately and the organ may be left looking, in Etcoff’s words, “a bit like a tied balloon.”

Her introduction promises that her argument “will be guided by cutting-edge research in cognitive science and evolutionary psychology.” In fact I found myself wishing that her book were more overtly scientific and intellectually tougher, particularly in questioning how far we can trust the findings of broadly phrased question-naires. She writes with an attractive élan, but in making a case for tolerance of plastic surgery she lacks Germaine Greer’s ability to thump home a theory of her own. Her stimulating book makes me rethink received notions of observation, pleasure, fetish, fashion, and natural and man-made beauty, leaving me with the feeling that there is still much more to say.

This Issue

October 7, 1999